HomeMy WebLinkAbout07-18-07 (2)
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15056051058
REV-1500 EX (06-05)
PA Department of Revenue *'
Bureau of Individual Taxes
PO BOX 280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
County Code Year
File Number
21 07
0337
Date of Birth
286-76-2101
04/02/2007
12/21/1970
Decedent's Last Name Suffix
Decedent's First Name
MI
Edmiston Jr.
Charles
M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
MI
N/A
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
eei 1. Original Return
2. Supplemental Return
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
4. Limited Estate
4a. Future Interest Compromise (date of
death after 12-12-82)
7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
o
8. Total Number of Safe Deposit Boxes
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
11. Election to tax under Sec. 9113(A)
(Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
Andrew H. Shaw, Esquire
Firm Name (If Applicable)
(717) 243-7135
First line of address
REGISTEllOf WILLS
'.:. :.:'-)
..:.-... - T 1
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(,~....
c::;
/....
200 S. Spring Garden St.
co
Second line of address
....,...,.
Suite 11
City or Post Office
State
ZIP Code
Carlisle
PA
17013
N
Correspondent's e-mail address:ashawlaw@comcast.net
Under penalties of pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
DATE
1- 'i' t Co'1
DATE
~ 9-07
ADD S5
200 S. Spring Garden St., Suite 11, Carlisle, PA 17013
PLEASE USE ORIGINAL FORM ONLY
L
15056051058
Side 1
15056051058
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15056052059
REV-1500 EX
Decedent's Name:
Charles
M Edmiston
RECAPITULATION
1. Real estate (Schedule A). .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1.
2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3.
4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5.
6. Jointly Owned Property (Schedule F) Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) Separate Billing Requested.. . . . . .. 7.
8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8.
9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10.
11. Total Deductions (total Lines 9 & 10)................................... 11.
12. Net Value of Estate (Line 8 minus Line 11) ... .. ...... ..... ...... ... .... . 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) .... . . . . . . . . . . . . . . . . . . . . 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ..... . . . . . . . . . . . . . . . . . . . 14.
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .O~
16. Amount of Line 14 taxable
at lineal rate X.O 45
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
0.00
15.
0.00
16.
0.00
17.
0.00
18.
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
L
15056052059
Side 2
286-76-21 01
Decedent's Social Security Number
15056052059
0.00
0.00
0.00
0.00
13,405.97
0.00
0.00
13,405.97
16,777.25
1,002.55
17,779.80
-4,373.83
0.00
-4,373.83
0.00
0.00
0.00
0.00
0.00
-I
R.EV-1500 EX Page 3
Decedent's Complete Address:
File Number
21
07 0337
DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER
Charles M Edmiston 286-76-2101
STREET ADDRESS
15 Cardinal Drive
CITY I STATE I ZIP
Carlisle PA 17015
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
0.00
0.00
0.00
0.00
Total Credits ( A + B + C ) (2)
0.00
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
0.00
0.00
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5A)
(5B)
0.00
0.00
0.00
0.00
0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due.
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; .......................................................................................... 0 [i]
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 [i]
c. retain a reversionary interest; or.......................................................................................................................... 0 [i]
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [i]
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 [i]
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 [i]
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0 [i]
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 P.S. 39116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax retum are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. 39116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. 39116(1.2) [72 P.S. 39116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. 39116(a)(1.3)]. A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX. (~") '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Charles M. Edmiston, Jr.
FILE NUMBER
21-07-0337
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Savings Account, Members 1st FCU, Account # 200355 3,783.04
2. Chevrolet S-10 Pickup Truck, VIN 1 GCCT19W3Y8275439 6,500.00
3. Payment from Employer for unused vacation time 1,124.24
4. Federal Income Tax Refund 1,740.00
5. Refund from Verizon Wireless 23.98
6. Miscellaneous receipt 215.00
7. Miscellaneous receipt 19.71
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
13,405.97
st
Send Inquires to:
5000 Louise Drive
PO Box 40
Mechanlcsburg, PA 17055
www.members1st.org
Statement of Accounts
Mar 25, 2007 thru Apr 24, 2007
@
Main Switchboard: (717) 697-1161 or (800) 283-2328
EZ Call: (717) 697-4372 or (800) 283-4372
TOO: (717) 697-5312 or (800) 283-2328 ex!. 5312
TeleBranch: (717) 795-6049 or (800) 237-7288
Account Number:
200355
MEMBERS 1st
FEDERAL CREDIT UNION
*-
---
~=
---
---
"'-
~=
0-
0-
*
5213 1 AV 0.293 10425-5213
1,"111", " 11","11"11",1,1,1,1,1",11"1",,11,"11,1"11
CHARLES M EDMISTON JR
CIO LAW OFFICE OF ANDREW H SHAW
200 SOUTH SPRING GARDEN ST SUITE 11
CARLISLE PA 17013
Account Balances at
Checking:
Savings:
Certificates:
Loans:
Money Management:
a Glance:
0.00
0.00
0.00
0.00
0.00
Page: 1 of 2
Your current Member Loyalty Reward level is Silver
Don't forget about Member Loyalty Rewards. The more products you have with us,
the more benefits you'll receive. Ask an associate for details or visit our
website at www.members1st.org.
CHECKING ACCOUNTS
11 - CHECKING
Date Transaction Description Additions Subtractions Balance
Mar 25 Balance Forward 0.00
Mar 30 Deposit Transfer From Share 00 28.50 28.50
Mar 30 Check 001084 Tracer 0330012623 28.50- 0.00
Apr 02 Deposit Transfer From Share 00 37.50 37.50
Apr 02 Withdrawal ACH GOLD'S GYM - CAR 37.50- 0.00
TYPE: Club Dues 10: 1521407387
Apr 02 Deposit Transfer From Share 00 100.00 100.00
Apr 02 Check 001085 Tracer 0029491896 100.00- 0.00
Processed Check - VZ WIRELESS ARC
TYPE: ARC 10: 2005091203
Apr 02 Deposit Transfer From Share 00 100.00 100.00
Apr 02 Check 001083 Tracer 0402009026 100.00- 0.00
Apr 03 Deposit Transfer From Share 00 203.80 203.80
Apr 03 Check 001086 Tracer 0403000240 203.80- 0.00
CHECKING Closed
"",;This is the final statement presenting information on this product....,;
,;.... Please retain this final statement for tax reporting purposes ....,;
CHECK SUMMARY
Check # Amount Date Check # Amount Date
001083 100.00 Apr 02 001085 100.00 Apr 02
00 1 084 28.50 Mar 30 001086 203.80 Apr 03
4 Checks Cleared for 432.30
SAVINGS ACCOUNTS
00 - REGULAR SAVINGS
Date Transaction Description Additions Subtractions Balance
Mar 25 Balance Forward 4,262.33
Mar 29 Withdrawal at ATM #005359 60.00- 4,202.33
ATM RGNL/MAC 5 EAST GATE DRIVE CARLISLE PA
Continued on following page - - -
~ 1.St.
MEMBERS I'
J-tUlR"I.CRHlI1 L''1111N
Send Inquires to:
5000 Louise Drive
PO Box 40
Mechanicsburg, PA 17055
www.members1st.org
Main Switchboard: (717) 697-1161 or (800) 283-2328
EZ Call: (717) 697-4372 or (800) 283-4372
TOO: (717) 697-5312 or (800) 283-2328 ex! 5312
TeleBranch: (717) 795-6049 or (800) 237-7288
10426-5213
Mar 25, 2007 thru Apr 24, 2007
Account Number: 200355
Page: 2 of 2
Date Transaction Descr; tion Additions Subtractions Balance -
Mar 30 Deposit ACH EXEL 1 448.90 4,651.23
TYPE: REG. SALARY ID: 1042801160
Mar 30 Withdrawal Transfer To Share 11 28.50- 4,622.73
Mar 31 Deposit Dividend 1.000010 3.55 4,626.28 -
Annual Percentage Yield Eamed 1. {}()(J}6 from 03/01/2007 through 03/31/2007
~ Apr 02 Withdrawal Transfer To Share 11 37.50- 4,588.78 -
.. Apr 02 Withdrawal Transfer To Share 11 100.00- 4,488.78 -
.. Apr 02 Withdrawal Transfer To Share 11 100.00- 4,388.78 -
..
; Apr 03 Withdrawal Transfer To Share 11 203.80- 4,184.98
~ Apr 06 Deposit ACH EXH 1 373.69 4,558.67
TYPE: REG. SALARY ID: 1042801160
- Apr 12 Withdrawal nS.97- 3 ,781 . 70
- Apr 12 Deposit Dividend 1.34 3,783.04
Annual Percentage Yield Eamed 1_oo(J}6 from 04/01/2007 through 04/11/2007
Apr 12 Withdrawal by Check 3,783.04_ 0.00
REGULAR SA VINGS Closed
.....This is the final statement presenting information on this product......
...... Please retain this final statement for tax reporting purposes ......
YTO SUMMARIES
TOTAL DIVIDENDS PAID
00 REGULAR SAVINGS
11 CHECKING
13.75
0.00
Add Your Photo For Security
Your personal safety and financial security are top priorities at Members 1st. As a result of
increased scams and fraudulent activity throughout the entire country, we are strongly
encouraging members to have their photos added to their account records. When visiting our
branch Offices, you may be asked by one of our Associates to allow us to takeJour photo. This
member identification program will assist in our fraud deterrence initiatives an will take our
identity theft prevention program to the next level. We are experiencing an increaSing number of
attempted fraudulent actIvities and as a result, we need to be able to verify your idenbty
immediately upon retrieving your account information.
In addition to having your photo in our files, you may be required to show additional fonns of
identification based on the type of transaction you are seeking. This is for your protection and
security and we appreciate your ongoing cooperation and understanding.
Total Year To Date Dividends Paid
NOTE: Total includes closed shares
Total Year To Date Interest Paid
NOTE: Total includes closed loans
13.75
0.00
I, Rosella Walton have paid $6,500.00 (Six thousand five hundred
dollars and no cents) to Charles Edmiston for a 2000 Chevrolet
S10 pickup truck;
vehicle identification number-l GCCT19W3Y8275439.
Payment in full was made on May 8, 2007
Rt,'IL.- !Jvtv
Rosella Walton
~~1J tJ 67
/
Date
Ch~-c. ~( ELI<fk
Charles Edmiston
s- - /~l> '7
Date
REV-1511 EX+ (12-99*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Charles M. Edmiston, Jr.
FILE NUMBER
21-07-0337
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
AMOUNT
B.
1.
2.
3.
4.
5.
6.
7.
DESCRIPTION
1.
FUNERAL EXPENSES:
Hoffman-Roth Funeral Home & Crematory, Inc.
Carlisle Memorial Headstone
Burial Lot
8,142.55
3,592.70
250.00
2.
3.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
0.00
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
. State
Zip
Year(s) Commission Paid:
Attom ey Fees
1,200.00
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
3,500.00
Claimant Charles M. Edmiston, Sr.
Street Address 15 Cardinal Drive
City Carlisle
State PA Zip 17015
Relationship of Claimant to Decedent Parent
Probate Fees
92.00
Accountant's Fees
0.00
Tax Return Preparer's Fees
0.00
16,777.25
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
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RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Rece~pt Date:
Rece=!-pt Time:
Recelpt No. :
4/09/2007
14:18:24
1047980
EDMISTON CHARLES M JR
Estate File No. :
Paid By Remarks:
2007-00337
CHARLES M EDMISTON
CJ
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS ADM
RENUNCIATION
SHORT CERTIFICATE
JCP FEE
AUTOMATION FEE
Check# 7599
Total Received.........
60.00
5.00
12.00
10.00
5.00
----------------
$92.00
$92.00
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
CUMBERLAND COUNTY GENERAL FUN
REV-1512 EX+ (12-03)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Charles M. Edmiston, Jr.
FILE NUMBER
21-07-0337
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
Royer's Gulf Service - Automotive repairs to vehicle
121.86
2.
Royer's Gulf Service - Automotive reparis to vehicle
497.34
3.
Sollenbergers Messenger Service - Duplicate registration to vehicle
70.50
4.
Sollenbergers Messenger Service - Duplicate title to vehicle
39.50
5.
Carlisle Regional Medical Center - Account #9365735
152.50
6.
Kinetic Imaging Inc. - Account # 9365735
3.75
7.
Lane. HMA Phys Mgmt Cent Penn - Account # 519413
17.10
8.
H&R Block - Preparation of 2006 Income Taxes
100.00
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
1,002.55
-".._-~~-_._. ."----~ -.----.-,--- ----.-----------.-----..-.-----
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,.
SAFETY "CAR-CHEK"
SERVICE
ROYER'S GULF SERVICE
,
263 YORK ROAD
,RT. 74, EXIT 49
CARLlSLE,J?,f\ 17013
PHONE: 243-7295
..
.. ~,B^'ITERY,ACC., }>ARTS
NAME
CITY
STATE
ZIP CODE
] - ,rOb
TELEPHONE NO.
I
.... . QUAN. CUSTOMER ORDER AMOUNT
f,;{ '.-,
" GASOLINE FlLL TANK 0
:"... .... GULFCRESTD ~OOD GULF 0 SUP. UNL. 0
< GULF AUTO DIESEL 0
iif:;~;:;
, LUBRICATION 0
MOTOR OIL C~GE ~ ADD 0
BRAND: (.. {hJ.Lr
c TRANSMISSION F ' J.J.~ CHANGE 0
TOTAL PARTS
DIFFERENTIAL ADD 0 CMNGE 0
CAR WASH 0
~ LABOR AND SERVICE WORK
~~(L \V OJ{ . he,...L \e
\ :\:\\ ~.Y'5 ~ lL,( J... ~J' ("
(l~~ (\.P-~T-
~ ~
/ ~ALABOVE
/ COMMENTS "
- to1 L PARTS
/ I TOT) IL LABOR ,,-
LYl C)
/ . [I J -
\1 'J 1 ^ '"', I l ~14 TAX
/ y.
D7 Jr..
-: \ / ,x c rn ' . ~'.
~ I ....
.. [i
\ f" ,,~ ..... PAY THIS 50
. AMOUNT
1\ ~ ~ . "
'...... ., -;:
, \\J "- , ;
..
.. ~ THANK YJ)fill:
~ .-.. K'~. ;:"t,~~rX;.t'~:'
27:0'1
.. ~ i I COSTOMER'S SIGNATUiE
,-:
TOTAL LABOR X
", .
1 ~~
~
..";;"
~r.~
;,:,;i3
TIllFS, BATTERY, ACe, PARTS
AMOUNT
TOTAL PARTS
LABOR AND SERVICE WORK
TCYtAl. LABOR
SAFETY "CAR-CHEK"
SERVICE
ROYER'S GULF SERVICE
263 YORK ROAD
RT. 74, EXIT 49
CARLISLE, PA 17013
PHONE: 243-7295
.20 oe
MAKE OF CAR
Q,hR~
MODEL
5-/D
ADDR88S
CITY
STATE
ZIPCOOB
o
MILlAGE
t+ .\~ \
0LV
DATil
5 ' ) 07
TELEPHONB NO.
QUAN. CUSTOMER ORDER AMOUNT
GASOLINE FILL TANK 0
GVLFCUsTD GOOD GUU' 0 SUP. UN!.. 0
GULF AUTO DIESEL 0
LUBRICATION ~ S- ~
MOroJt OIL CHANGE...~~ (YD 0
BRAND: 15 ID
'l'KANSMISsJON ADD 0 ~EO
DD'FERENTIAL ADD 0 CHANGE 0
CAR WASH 0
TOTAL ABOVI!: ,.;z.O . sV
COMMENTS /8/ 19
TOTAL PARTS
TOTAL LABOR UI SO
TAX 2..8'" ()
PAVnus ifft
AMOUNT 3l/
..
(~ .
~"TOMER'B SIGNATURE
THANK YOU!
4123
x
C, I .'~ ~.
,Messenger Service Receipt
. ... SOLLENBERGERSMESSENGlfR SERV
..2 9 WESTMINSTER-DRIVE
.CARLISLE, PA 17013
717-249-814-9
For: CHARLES M EDMISTpN
15 CARDINAL DR
CARLISLE, PA 17013
717-243-9313
Invoice #: 16940
Date: 04/23/07
Time: 09:47 AM
Clerks Initials: DS
File Name: CARL07
Title # or Date of Birth: 55038785101
VIN or Driver's Number
Tag Number or Eye Color YBA6920
-Year-Make or Soc. Sec.#
Transaction MVI05/39
Odometer 0
Comments:
ONLINE
This item will be Mailed to you.
WARNING: Bureau regulation require that any
item left in our office for 60 days be
returned to the Bureau of Motor Vehicles as
unclaimed.
I/We swear that I/we have applied for the
above item(s) .
Sworn & subscribed to before me on 04/23/07.
Notary
Seal
State Fees
Title Fee........ . . . . .
Encumbrance Fee.. . . . . .
Tag Transfer. .........
Registration......... .
Dup. Fee..............
Increase Fee..........
Replacement Fee.......
Tax-On $0.00....
Total State Fee.......
Check #.... . . . . . . . . . . .
0.00
0.00
0.00
58.50
0.00
0.00
0.00
0.00
0.00
0.00
58.50
Service Fees
Messenger Fee.........
Temp Tag Fee..........
Notary Fee. . . . . . . . . . . .
Copy/Fax Fee..........
Document Fee.. ........
Check or M.O. Fee.....
12.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total Service Fee..... 12.00
Service Fee Check #... 103
SOLLENBERGERS MESSENGER SERV
Grand Total... ........
Total Due..... ........
Amount Paid...........
Paid in Full
70.50
70.50
70.50
No Refunds on Service or
Notary f~es. We are not
responsible for work the
State fails to process.
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vnMn\Jt:..:J ,....~r-r-CMfir'..,,1J VI"l ! nJ0 ..:) IMl CIVICI\lI /'"\nc .'tV I lI'4'-'L.ULlCU VI'I,l (""'\1.... I I IV<Jr I InL. UIL-L. '-Ill V Inl L..,IVIL..I'I I
_ EXPLANATION OF ACTIVITY \
PATIENT NAME
CHARGES
AND DEBITS
PAYMENTS
AND CREDITS
10107 GUARRACINO EMERGENCY VISIT INV#:l EDMISTON,CHARLES 285.00
AMOUNT TO BE PAID BY CO INS $17.10
050107 AETNA POS PAYMENT -96.90
050107 AETNA POS ADJUSTMENT -171.00
Insurance Balance: 0.00 Patient Balance: 17.10
&\
. 1
~ ~I
~; f
atement
lte:
06/01/07
PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE
519413
Current
0.00
31-60 Days
17.10
61-90 Days
0.00
>90 Days
0.00
Total
Ins Pending
PATIENT BALANCE
PAY THIS AMOUNT
17.10
0.00
17.10
END INQUIRIES I PAYMENTS TO:
LANe lIMA PHYS MGMT CENT PEN
PO BOX 619
EAST PETERSBURG, PA 175200619
717 519-0753
"t.........-rr. r"L_.____ __...J --.--__~_ __~ ______:__ __ .L..'_ _.._.._____~...:" ______ __ ____J.. ____u...'... _....""....____,
REV~513 EX+ (9-00)
'*
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Charles M. Edmiston, Jr.
FILE NUMBER
21-07-0337
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. Charles M. Edmiston, Sr. and Barbara Edmiston Parents
15 Cardinal Drive, Carlisle, PA 17015
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.00
(If more space is needed, insert additional sheets of the same size)